Utilization and outcomes of inpatient surgical care at critical access hospitals in the United States

Abstract

Importance: There is a growing interest in the quality and cost of care provided at Critical Access Hospitals (CAHs), a predominant source of care for many rural populations in the United States.

Objective: To evaluate utilization, outcomes, and costs of inpatient surgery performed at CAHs.

Design, setting, and patients: A retrospective cohort study of patients undergoing inpatient surgery from 2005 through 2009 at CAHs or non-CAHs was performed using data from the Nationwide Inpatient Sample and American Hospital Association.

Exposure: The CAH status of the admitting hospital.

Main outcomes and measures: In-hospital mortality, prolonged length of stay, and total hospital costs.

Results: Among the 1283 CAHs and 3612 non-CAHs reporting to the American Hospital Association, 34.8% and 36.4%, respectively, had at least 1 year of data in the Nationwide Inpatient Sample. General surgical, gynecologic, and orthopedic procedures composed 95.8% of inpatient cases at CAHs vs 77.3% at non-CAHs (P < .001). For 8 common procedures examined (appendectomy, cholecystectomy, colorectal cancer resection, cesarean delivery, hysterectomy, knee replacement, hip replacement, and hip fracture repair), mortality was equivalent between CAHs and non-CAHs (P > .05 for all), with the exception that Medicare beneficiaries undergoing hip fracture repair in CAHs had a higher risk of in-hospital death (adjusted odds ratio = 1.37; 95% CI, 1.01-1.87). However, despite shorter hospital stays (P ≤ .001 for 4 procedures), costs at CAHs were 9.9% to 30.1% higher (P < .001 for all 8 procedures).

Conclusions and relevance: In-hospital mortality for common low-risk procedures is indistinguishable between CAHs and non-CAHs. Although our findings suggest the potential for cost savings, changes in payment policy for CAHs could diminish access to essential surgical care for rural populations.

Figure 1

Proportion of hospitals performing at least 5 inpatient surgical specialty procedures in one year according to Critical Access Hospital designation. p <0.01 for all specialty comparisons. CAH, Critical Access Hospitals.

Figure 2

Adjusted hospital costs associated with surgical admissions according to Critical Access Hospital designation. A, All patients. B, Patients with Medicare as primary payer. C, Elective admissions. Total costs were calculated from total charges, hospital specific cost-to-charge ratios, and principal diagnosis adjuster. Costs adjusted for patient variables, length-of-stay, and rural/urban location of admitting hospital. Error bars represent 95% confidence intervals. p <0.01 for all procedure comparisons. CAH, Critical Access Hospitals; CRC, colorectal cancer.